Review Article

Defining Skin Quality: Clinical Relevance, Terminology,

and Assessment
Shannon Humphrey, MD, FRCPC, FAAD,*† Stephanie Manson Brown, MBBS, MRCS,‡ Sarah J. Cross, PhD,§ and
Rahul Mehta, PhDk

BACKGROUND Flawless skin is one of the most universally desired features, and demand for improvements in skin
quality is growing rapidly. Skin quality has been shown to substantially impact emotional health, quality of life, self-
perception, and interactions with others. Although skin quality improvements are a common end point in studies of
cosmeceuticals, they are rarely assessed in clinical studies of other aesthetic treatments and products. Descriptive
terminology for skin quality parameters also varies considerably within the aesthetic field, relying on a range of redundant
and occasionally contradictory descriptors. In short, skin quality has not been clearly defined.
OBJECTIVE The goal of this review is to highlight the importance of skin quality to patients and physicians, explore known
and unknown factors comprising skin quality, and provide clarity regarding terminology, descriptors, and evaluation tools
for assessing skin quality.
MATERIALS AND METHODS A review of the literature on skin quality was performed without limitation on publication
date. Relevant articles are presented.
RESULTS AND CONCLUSION We propose a framework of attributes contributing to skin quality rooted in 3 fundamental
categories—visible, mechanical, and topographical—with the aim to provide information to help guide clinicians and inform
future clinical studies.

A ccording to psychologist Nancy Etcoff,1 identifi-

cation of beauty is intuitive, whereas definition of
beauty is subjective, mutable, and difficult to for-
mulate into words. As the cornerstones of beauty include
smooth, healthy looking skin, what comprises desirable
skin is similarly difficult to define. Yet, flawless skin is an
important component of facial attractiveness and continues
to be one of the most universally desired features.1–3 In a
recent global survey, 94% of the 14,584 people interviewed
desired to improve their facial skin, and terms such as
From the *Humphrey Cosmetic Dermatology, Vancouver, British Columbia, Canada;
†
Department of Dermatology and Skin Science, University of British Columbia,
Vancouver, British Columbia, Canada; ‡ Allergan Aesthetics, an AbbVie Company,
Marlow, United Kingdom; § AbbVie Inc, Irvine, California; kAllergan Aesthetics, an
AbbVie Company, Irvine, California
S. Humphrey is a speaker, consultant, and/or investigator for Cutanea, Evolus,
Galderma, L’Oreal, Merz, Bonti, Revance, and Allergan Aesthetics, an AbbVie
company. S. Manson Brown and R. Mehta are employees of Allergan Aesthetics, an
AbbVie company. S. J. Cross is an employee of AbbVie, Inc. Medical writing was
provided by S. J. Cross of AbbVie and funded by AbbVie, Inc.
Address correspondence and reprint requests to: Shannon Humphrey, MD,
Department of Dermatology and Skin Science, University of British Columbia, 943
West Broadway, #820, Vancouver, BC V5Z 4E1, Canada, or e-mail: shannon@
humphreyderm.com
Copyright © 2021 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf
of the American Society for Dermatologic Surgery. This is an open-access article
distributed under the terms of the Creative Commons Attribution-Non Commercial-
No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and
share the work provided it is properly cited. The work cannot be changed in any way
or used commercially without permission from the journal.
Supplemental digital content is available for this article. Direct URL citations appear
in the printed text and are provided in the HTML and PDF versions of this article on
the journal’s Web site (www.dermatologicsurgery.org).
http://dx.doi.org/10.1097/DSS.0000000000003079
radiance and healthy, glowing skin are requested by pa-
tients seeking improvements in their appearance (un-
published data, Allergan Aesthetics). The encompassing
term for this collection of desired outcomes is skin quality.
Skin quality as a concept is gaining traction in the aesthetic
field worldwide. Rejuvenation procedures, cosmeceuticals, and
minimally invasive injectable therapies are increasingly popular.
However, reaching a consistent, objective definition of skin
quality has been difficult. Current literature focuses heavily on
age-related changes in skin quality, rather than skin quality per
se, and descriptive terminology has substantial variability
between investigators and geographically (See Supplemental
Digital Content 1, Table S1, http://links.lww.com/DSS/A795
for levels of evidence of included literature). The lack of a clear,
comprehensive definition precludes identification of clinical
indicators and evaluation tools necessary for proper assessment
and treatment of undesirable skin quality. In short, skin quality
has yet to be clearly defined. Thus, the authors’ goal is to
elucidate the importance of skin quality to patients and aesthetic
physicians, explore and understand what factors comprise it,
and identify the gaps in the authors’ understanding. The
authors then propose a novel classification of skin quality
attributes to provide clarity for both patients and physicians.
Importance of Skin Quality
Biological and
Evolutionary Perspectives
The appearance of one’s skin provides a wealth of
information about an individual. Skin health is intricately
linked to overall well-being, and clear skin is one of the
body’s “visual certificates of health,”1 reflecting general

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health and vitality, as well as disease and nutritional
state.4–10 The visible condition of skin can also validate
reproductive health and fertility.11 Attributes of skin quality
(e.g., texture and homogenous coloration) contribute to
perceptions of facial attractiveness,2 which may then
correlate with mate choice and mating success,12 potentially
because of the condition of one’s skin indicating the quality
of his/her immune system.2 Indeed, increasing evidence
supports a link between immune health and facial
attractiveness,13–15 although more research is needed to
fully understand the contribution of individual skin quality
attributes to this relationship. In addition, men may perceive
female skin as more attractive and healthier during the
fertile (i.e., late follicular) phase of the menstrual cycle,16–18
although data are equivocal and suggest minor variations in
chromophore distribution could be the driver.16,19
Present characteristics of skin evolved in consideration of
health, disease, and sexual selection. Human’s relative
hairlessness was an adaptation to ward off parasites1 and
combined with the development of sweat glands to allow for
efficient heat dissipation.20 A rich vascular network evolved to
support skin’s sweat glands, hair follicles, and multiplying
cells,20 while a diverse symbiotic microbiome that varies
across sex, age, skin site, and geographical location influences
attributes of skin quality and, in cases of dysbiosis, skin
disorders.21–25 Variations in skin pigment evolved in response
to geographic differences in ultraviolet (UV) radiation, with
increased melanin content in high UV areas as a means of
photoprotection, and paler skin evolving for lower-light
environments and enhanced vitamin D synthesis.1,20,26,27
Anthropologic data also suggest that, within a society, women
evolved with lighter skin than men, so that signs of attraction,
such as flushing or blushing, would be more apparent.28
Much of the authors’ understanding of biological factors
comprising skin quality has been elucidated through studies
of aging, although a full discussion is outside the scope of
this article. Briefly, intrinsic aging is associated with
structural and functional deterioration of the skin, with
declines in collagen, elastin, chondroitin, and hyaluronic
acid, among other components.29–31 Together with other
age-related alterations and damage, these changes lead to
decreases in barrier function and hydration and concomi-
tant increases in sagging, pore size, wrinkles and deep
expression lines, dullness, blotchiness, rough texture,
hyperpigmentation, dryness, and erythema.20,30,32–39
Skin aging literature has also highlighted variation in skin
quality among individuals of different ethnicities, which
remains understudied within aesthetics. Despite the widely
considered protective effect of increased melanocytes and/or
melanin, both intrinsic aging and photoaging occur, rendering
skin less resilient and elastic.40 In addition, age-related changes
in pigmentation, pore size, elasticity, oiliness, and thickness may
differ between men and women of the same ethnicity.41–43 The
appearance of facial pores also varies among ethnic groups,
with Asians having the smallest pores compared with African
American, white, and Hispanic subjects, and African Ameri-
cans having the most severe impairment of the structure
surrounding facial pores.43 Furthermore, the effects of
Defining Skin Quality • Humphrey et al
photoaging differ across skin phototypes, with lighter skin
more prone to depigmentation, atrophic changes, and skin
cancers, and darker skin more prone to hypertrophic skin
changes, deep wrinkles, and skin thickening.33 In short, the
appearance of skin speaks to the biological underpinnings of
health and reproductive fitness, with important, but under-
studied, differences across ethnicities.
Psychosocial Impact
Physical appearance and perceptions of attractiveness are
multifactorial and intricately linked.44 As a result, the
quality of one’s skin has a strong psychosocial influence on
individuals. Poor skin quality can result from a myriad of
factors and may negatively impact a person’s emotional
health, quality of life, self-perception, and interactions with
others.45–47 Importantly, self-perception is affected by
interactions with, and judgements by, others. Multiple
studies have shown that skin, as a person’s primary
interface with their surroundings,26 influences others’
judgments of one’s health, personality traits, youthfulness,
and emotional and psychological well-being.48–50 Studies
investigating manipulations of skin surface topography in
photographs of middle-aged women found that small
topographic skin alterations significantly influenced ob-
servers’ preferences for specific faces and perceptions of age
and attractiveness.19 In another study of facial photographs
of women aged 40 to 71 years, removal of age spots,
telangiectasia, furrows, lines, and wrinkles significantly
impacted raters’ perceptions of age and health.51 Further-
more, increasing evidence suggests that noninvasive facial
rejuvenation produces sustained improvements in self-
esteem, self-ratings of attractiveness, and decreases self-
perceived age.52–56 Together, these data highlight the
significant psychosocial impact of skin quality and potential
for improvements using aesthetic procedures.
Indeed, improvement of skin quality is an increasingly
common objective of clinical studies of aesthetic treatments
and the primary goal of such treatments in clinical
practice.9,37,57–63 According to a recent prospective, multi-
center, observational study of 511 subjects seeking cosmetic
procedures, approximately 80% of subjects said a desire for
a youthful, more attractive appearance and clear skin
motivated them to seek aesthetic treatment; other common
reasons included improving psychosocial well-being, look-
ing good professionally, and feeling less self-conscious
around others.64 In addition, clinical studies use several
instruments (e.g., Skindex-16 and FACE-Q) to measure
postprocedure subject satisfaction with skin and the
psychosocial impact of treatment,65 highlighting critical
links between skin’s appearance and psychosocial factors.
Attributes of Skin Quality: Approaching
a More Rigorous Definition
Defining Skin Quality
Despite the growing awareness and importance of skin quality
in human evolution, psychology, aesthetic treatments and
practice, and clinical research, there is a dearth of literature
www.dermatologicsurgery.org 975
and a lack of consistency in descriptive terminology for skin
quality parameters. Studies of the effects of cosmetic products
and procedures on skin quality rely on a range of often
redundant, and sometimes contradictory, descriptors that are
rarely defined (See Supplemental Digital Content 2, Table S2,
http://links.lww.com/DSS/A796). It is imperative to establish
scientific rigor surrounding the definition and measurement of
skin quality to guide the development and implementation of
appropriate treatment strategies.
The authors propose a framework of attributes contrib-
uting to skin quality in healthy skin rooted in 3 fundamental
categories: visual, mechanical, and topographical (Figure 1,
Table 1). Visual attributes are purely visible, even after
completely smoothing away topographic imperfections on
the skin, and are assessed by light’s reflection onto the skin.
Topographical attributes are perceived by touch and viewed
by topographic imagery. Mechanical attributes are related
to how skin moves and can be measured by physical
manipulation or deformation of the skin. To overcome
Figure 1. Proposed framework of skin quailty attributes.
inconsistencies in terminology currently applied to skin
quality, Table 1 defines individual attributes based on the
authors’ clinical experience and Supplemental Digital
Content 2, Table S2, http://links.lww.com/DSS/A796 in- visible), were not included as a skin quality attribute
cludes a review of the limited descriptions in the literature; a because they are a secondary skin lesion rather than a
summary of considerations related to each attribute primary attribute of skin quality.
follows. It is important to note that these categories are
not mutually exclusive; individual attributes may fit into Visual Attributes
multiple categories. Furthermore, scars, which relate to all 3 Uneven pigmentation, which often refers specifically to
proposed categories of skin quality (as they are palpable, variations in melanin, is a primary visual attribute based on
affect the movement of skin at the scar site, and are readily skin’s melanin content; darker skin is richer in melanin.1,20

TABLE 1. Proposed Skin Quality Attributes and Their Definitions

Attribute Definition
Uneven pigmentation Variation in melanin
Redness Erythema or visible hemoglobin
Dullness/sallowness Absence of glow; yellow or grayish undertone
Radiance Ability of skin to “glow” or reflect light
Oiliness/shine Excess sebum on the skin surface
Dryness Lack of moisture; dehydration
Roughness Uneven, not level texture
Fine lines Light wrinkles
Coarse lines Deep wrinkles
Pores Surface landmark of pilosebaceous unit
Crepiness Fine cigarette paper wrinkling of skin
Hydration Water content; moisturization
Laxity Loose skin
Elasticity/pliability Ability to recoil with manipulation
Firmness Relative ability to be stretched
Thickness Density of the epidermis and dermis

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Photoaged skin may show areas of hypopigmentation or
hyperpigmentation, whereas melasma appears as hyperpig-
mented patches in a characteristic distribution, both giving
the appearance of mottling or blotchiness.9 Redness
(erythema) relates to underlying skin color and relative
vascular burden and visibility through the skin.17,66,67
Dullness and sallowness refer to the lack of natural radiance
and may be associated with a yellow undertone to the skin.
These are additional visual signs of poor skin quality, which
may result from myriad causes.9 On the opposite side of the
spectrum is the ability of the skin to reflect light, which the
authors term radiance or “glow”; radiance is both visual
and tactile because it depends on hydration levels and the
amount of dead or dry skin accumulation blocking light
reflection.68 Oiliness/shine and dryness are similarly visual
and tactile attributes. Oiliness, or excess sebum production,
may result from intrinsic (hormonal) or extrinsic (oxidative
stress) factors.33,39,68 Hydration is perceptible by sight,
touch, and biomechanics; that is, the moisture level of the
skin can be seen and felt and affects the skin’s ability to be
manipulated.69
Topographical Attributes
Topographical attributes are also visible, but are measured
by topographic methods. These attributes include smooth-
ness or roughness (texture); this component is an important
indicator of the presence or absence of aging or photo-
damage, considering extremely coarse skin may signal
elastosis,70 and smooth skin is considered younger-look-
ing.61 Topographical attributes also include the presence of
fine or coarse lines or wrinkles.71 Enlarged pores relate to
topographical properties of skin and have been correlated to
increased sebum production, advancing age, and male
sex.39 Skin crepiness may appear where underlying
structural support is lost (e.g., fat and/or muscle atrophy,
degradation of collagen and elastin fibers), leaving thin skin
hanging loosely in its place.32
Mechanical Attributes
Elasticity, or recoilability, is a mechanical property of skin
that decreases with compromised integrity of the network of
dermal elastic fibers.30,61 Firmness of the skin relates to its
pliability and has been an important effectiveness measure
in studies of aesthetic treatments.59,68 Thickness and
tightness of the skin—overly thick or thin skin and tight
or loose skin—are also mechanical properties impacted by
aging, whether intrinsic or extrinsic; excessive thickness and
sagging skin have been attributed to variations in epidermal
and dermal thickness or morphologic changes related to sun
exposure and aging.20,72
Skin Quality Assessment
and Measurement
Objective measurement of skin quality includes a variety of
techniques (See Supplemental Digital Content 3, Table S3,
http://links.lww.com/DSS/A797).101-125 Skin elasticity and
firmness can be measured by a Cutometer probe, which
Defining Skin Quality • Humphrey et al
generates a dislocation/relaxation curve based on manipu-
lation of the skin with the application and release of
negative pressure.63,73 Other probe-based techniques for
elasticity and firmness assessment are dermal skin torque
meter, indentation, or angular rotation techniques.68,74
Corneometers measure hydration by evaluating epidermal
capacitance in the stratum corneum, while other instru-
ments measure electrical impedance to assess skin hydra-
tion.75 Measurement of changes in pigment uses light
absorption and reflectance to assess melanin and hemoglo-
bin with Mexameter or full spectrum color analysis using
standard CIEL*a*b* protocol with Chroma Meter.76
Assessment of topography or morphology often rely on
high-definition imaging techniques and 3D fringe pro-
jection or modeling.68,74,77 The number and precision of
measurement tools for skin quality assessment continues to
grow (See Supplemental Digital Content 3, Table S3, http://
links.lww.com/DSS/A797), but as reviewed below, sub-
stantial knowledge gaps remain.
Treatments Targeting Skin
Quality Improvements
Current treatments and procedures targeting skin quality
improvements include rejuvenation procedures (e.g., chem-
ical peels, microneedling, laser, high-intensity focused
ultrasound, and dermabrasion), cosmeceuticals, and oral
supplementation (i.e., ‟nutraceuticals”31,78–81), among
others. Increasing evidence supports skin quality changes,
including improved texture, elasticity, pliability, hydration,
and oiliness, from minimally invasive injectable procedures
(e.g., botulinum toxin and intradermal fillers).56,82–88
However, larger, well-controlled studies are needed to
better understand the effects of neurotoxins and fillers on
skin quality. As with measurement and assessment tools,
knowledge gaps remain in our understanding of treatments
for skin quality improvement.
Gaps in our Understanding
and Knowledge
There remain inconsistencies and gaps in the literature
regarding how skin quality attributes are described, defined,
and tested (See Supplemental Digital Content 2 and 3, Table
S2 and Table S3, http://links.lww.com/DSS/A796 and http://
links.lww.com/DSS/A797). The rare definition of a specific
skin quality characteristic, such as hydration or elasticity, is
generally based on mechanical parameters or calculations
derived from measurement tools and instruments (e.g.,
Corneometer). Thus, clinical practice expertise shapes the
evaluation and interpretation of most attributes, which may
lead to variability in clinical practice and study. Similarly,
although skin quality can be broken down into component
parts, some attributes may be dependent on others. For
example, redness may reflect the degree of microscopic
vascularity visible under Fitzpatrick phototype I skin.
Measurement tools for skin quality also have other
limitations. Objective measurements are often used in
isolation and are allocated mainly to studying the effects
www.dermatologicsurgery.org 977
of aging, which lack substantiation in assessments of overall
skin quality.68,74 Furthermore, since skin properties differ
based on the area of the face (e.g., chins have the highest
pH89) and probe-based tools can only analyze small
portions of facial skin, these measurements may not provide
accurate representation of overall facial skin quality.
Furthermore, objective measurement tools may only be
able to assess one attribute at a time and may identify
statistically significant, but nonclinically relevant, changes
in skin quality. Future studies should consider use of
multiple objective tools, as well as combining objective and
subjective photonumeric grading of skin quality parame-
ters. However, subjective assessment tools (e.g., clinical
rating scales) are generally not inclusive of all skin types or
ethnicities,70,90–92 which needs to be addressed.
Imaging, in particular, is a useful tool for objectively
measuring skin quality attributes (See Supplemental Digital
Content 3, Table S3, http://links.lww.com/DSS/A797).
Image acquisition (e.g., exposure and angle) and analysis
parameters are not currently standardized in aesthetics, but
the growing availability of increasingly sensitive instru-
ments, computer-aided image analyses, and artificial in-
telligence with machine learning make these methods
promising for obtaining high-quality, objective measure-
ment of skin quality attributes. Finally, aesthetic procedures
and a desire for skin quality improvements are gaining in
popularity among individuals with skin of color, although
we still have a limited understanding of distinctions in skin
quality attributes across ethnicities.63,93–98
Conclusion
The importance of facial attractiveness is well documented
and undeniable. Since the early 20th century, clinical
literature has highlighted the substantial influence of
physical appearance on attractiveness and the psychological
benefits of cosmetics and aesthetic procedures.44,99 Almost
100 years later, attaining a healthier, more attractive
appearance and clear skin is a major motivation in seeking
aesthetic procedures.100 The undercurrent in these obser-
vations is a desire for impeccable skin quality. Although
there is no shortage of literature detailing the effects of
visible skin condition on physical, psychological, and
emotional well-being and the substantial psychosocial
impact of aging skin, limited data are available explicating
the topic of skin quality parameters and their rapidly
growing importance in clinical settings. This review aims to
address this literature gap, focusing on clarity regarding
terminology, descriptors, and evaluation tools of skin
quality. This information is intended to help guide clinicians
who treat subjects concerned about skin appearance and
inform future clinical studies.
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